psoriasis [9,10].

The clinical impact of these data may contribute to

the prognosis and disease-specic therapies.
References
[1] Barker JNWN. Genetic aspects of psoriasis. Clin and Exp Dermatol 2001;26:3215.
[2] Hajeer AH, Hutchinson IV. Inuence of TNFa gene polymorphisms on TNFa
production and disease. Hum Immunol 2001;62:11919.
[3] Henseler T, Christophers E. Psoriasis of early and late onset: characterization of
psoriasis vulgaris. J Am Acad Dermatol 1985;13:4506.
[4] Miller AS, Dykes DD, Polesky HF. A simple salting out procedure for extracting
DNA for human nucleated cells. Nucleic Acids Res 1988;16:1215.
[5] Olerup O, Zetterquist H. HLA-DR typing by PCR amplication with sequence-
specic primers (PCR-SSP) in 2 h: an alternative to serological DR typing in
clinical practice including donor-recipient matching in cadaveric transplanta-
tion. Tissue Antigens 1992;39:22535.
[6] Udalova IA, Nedospasov A, Webb GC, Chaplin DD, Turetskaya RL. Highly
informative typing of the human TNF locus using six adjacent polymorphic
markers. Genomics 1993;16:1806.
[7] Stephens M, Smith NJ, Donnelly P. A new statistical method for haplotype
reconstruction from population data. Am J Hum Genet 2001;68:97889.
[8] Ho hler T, Grossmann S, Stradmann-Bellinghausen B, Kaluza W, Reuss E, de Vlam
K, et al. Differential association of polymorphisms in the TNFa region with
psoriatic arthritis but not psoriasis. Ann Rheum Dis 2002;61:2138.
[9] Biral AC, Magalhaes RF, Wastowski IJ, Simoes R, Donadi EA, Simoes AL, et al.
Association of HLA-A, -B, -C genes and TNF microsatellite polymorphism with
psoriasis vulgaris: a study of genetic risk in Brazilian patients. Eur J Dermatol
2006;16:5239.
[10] Magalhaes RF, Biral AC, Kraemer MH. Psoriasis in childhood with total remis-
sion x chronic disease: clinical application of HLA class I markers. J Dermatol
Sci 2007;46:778.
A.C. Biral
a,
*, R.F. Magalhaes
b
, I.J. Wastowski
c
,
R. Simoes
c
, E.A. Donadi
c
, A.L. Simoes
d
, C.T. Mendes-Junior
e
,
M.H.S. Kraemer
a
a
Immunogenetic Transplant Laboratory, Department of Clinical
Pathology, Faculty of Medical Sciences,
University of Campinas, 13083-887 Campinas, Sao Paulo, Brazil
b
Dermatology Division, Department of Medical Clinical,
Faculty of Medical Sciences, University of Campinas,
Campinas, Brazil
c
Department of Biochemistry and Immunology,
School of Medicine of Ribeirao Preto,
University of Sao Paulo, Ribeirao Preto, Brazil
d
Department of Genetics, School of Medicine of Ribeirao Preto,
University of Sao Paulo, Ribeirao Preto, Brazil
e
Department of Chemistry, Faculty of Philosophy,
Science and Letters of Ribeirao Preto,
University of Sao Paulo, Ribeirao Preto, Brazil
*Corresponding author. Tel.: +55 19 35217459;
fax: +55 19 35219434
E-mail address: anabiral@yahoo.com.br (A.C. Biral)
29 July 2009
doi:10.1016/j.jdermsci.2009.05.004
Letter to the Editor
Analysis of variation in the IL7RA and IL2RA genes in atopic
dermatitis
Atopic dermatitis (AD) is a chronic inammatory skin disease
with a complex genetic background. It belongs to the group of
atopic disorders that are characterized by a T helper (Th) type 2-
dominated immune response. Recent evidence suggested that
atopic diseases and autoimmune disorders (which are mainly Th1-
driven) may not be mutually exclusive, but rather share certainrisk
factors that increase the development of either Th1- or Th2-
immune responses to non-pathogenic antigens [1].
The genes encoding the interleukin (IL) 7 and the IL2 receptor a
chains (IL7RA and IL2RA) were recently identied as susceptibility
genes for multiple sclerosis (MS), a Th1-dominated complex
neuro-inammatory disorder. In IL7RA, a coding single nucleotide
polymorphism (SNP) in exon 6 (rs6879732) was identied as the
likely causal variation and shown to be functionally relevant [2]. In
the IL2RA gene, signicant associations with MS were found for
two SNPs in intron 1 [2].
Given the possible coincidence of Th1- and Th2-mediated
diseases, we speculated that variation in these two receptor genes
may also play a role for AD pathogenesis. Further, both receptors
appear to be involved in immune regulation in AD. For example,
thymic stromal lymphopoetin, a recently discovered IL7-like
cytokine that utilizes the IL7Ra chain as part of its receptor
complex, was claimed to be a crucial mediator of allergic
inammation [3]. Further, IL2 receptor signaling is involved in
the development and homeostasis of regulatory T cells which also
play an important role in AD pathogenesis, and serum levels of
soluble IL2R were found elevated in AD [4]. Interestingly, the
region 5p13 harbouring the IL7RA gene as well as a region in the
vicinity of the IL2RA gene (10p13) showed linkage to AD in a
Swedish linkage screen [5], pointing to both genes as potential
susceptibility genes for this chronic skin disease.
Thus, we evaluated the role of IL7RA and IL2RA variation in a
large German casecontrol cohort comprising 362 patients with
AD according to the criteria of Hanin and Rajka (145 males, 217
females; mean age of 18.6 years) and 908 non-atopic control
subjects (455 males, 452 females, mean age of 48.2 years) fromthe
Rhein-Ruhr area (Germany). DNA samples were obtained via
isolation from peripheral white blood cells. Informed consent was
obtained fromall patients and controls. The study was approved by
the Ethics Committee of the Medical Faculty of the Ruhr-University
Bochum, Germany.
SNPs were selected for genotyping that had shown signicant
association with MS in previous studies [2] or could be of potential
functional relevance (coding or promoter SNPs). Five SNPs were
genotyped in the IL7RA gene and 4 SNPs in the IL2RA gene via
TaqMan1 assays or polymerase chain reaction with subsequent
restriction fragment length polymorphismanalysis as described in
detail before [6]. Allele and genotype frequencies were compared
using x
2
tests with subsequent Bonferroni correction. Hardy-
Weinberg equilibrium (HWE) was evaluated using Pearsons
goodness-of-t x
2
test (degree of freedom = 1). Haplotype analyses
were performed using PHASE 2.1. Power analysis was performed
with the G*Power software assuming a small effect size of 0.20 for
the respective variation, a = 0.05 and degree of freedom (DF) = 2.
Power calculations revealed 93.6% statistical power to detect
signicant differences in allele or genotype frequencies between
AD patients and controls. All SNPs were in HWE in patients and
controls except for rs11256369 in the IL2RA gene which showed a
slight deviation from HWE in the controls (uncorrected p = 0.011).
Genotyping errors were excluded by random re-evaluation.
In the IL7RA gene, we found signicant differences in allele and
genotype distributions between AD patients and controls for the
exon 6 SNP rs6897932 (uncorrected p= 0.0017, after Bonferroni
correction p
c
= 0.0085; Table 1). Furthermore, a signicant
association of the intron 6 SNP rs987106 with AD was evident
(p
c
= 0.01). In contrast, we did not nd any signicant association
Letters to the Editor / Journal of Dermatological Science 55 (2009) 123141 138
with the four analyzed SNPs in IL2RA (Table 1). Haplotype
frequencies in both genes did not differ between AD patients
and controls (Table 2).
IL7RA represents the most consistently replicated susceptibility
gene for MS besides the HLA class II region to date. Here, we
demonstrate for the rst time that polymorphisms in this gene also
showassociation with AD, a chronic inammatory Th2-dominated
disorder. IL7RA is located in a region that has shown linkage to both
AD [5] and asthma [7]. In addition, ne mapping studies revealed
association of polymorphisms in this gene with asthma in both the
Hutterites and a cohort of Caucasian children [7] and association
with inhalation allergy was recently reported in a Scandinavian
study [8]. These results underline the hypothesis that IL7RA
variation may play a role in the pathogenesis of atopic disorders.
Interestingly, IL7RA is not the rst T cell regulatory gene that
showed overlapping evidence for association with both MS and AD.
For example, the 590 C/T promoter SNP in the IL4 gene was
associated with both diseases [5,9]. Further, IL10 promoter
polymorphisms were associated with risk for AD [5] and with
severity and disease progression in MS [10]. Thus, it appears that
genetically determined differences in immune response and
cytokine regulation may confer risk to various complex diseases.
Additional association studies in large cohorts as well as
expression studies are warranted in order to clarify the role of
IL7RA variation for the diseases investigated here as well as other
immune-mediated diseases.
Evaluation of IL2RA SNPs on the other hand revealed no
signicant associations for AD in this cohort. In addition to the
aforementioned association with MS, IL2RA variation has been
implicated in the pathogenesis of type 1 diabetes, systemic lupus
erythematosus and Graves disease [11]. To our knowledge, no
association studies for atopic disorders have been undertaken so
far in this gene. Thus, it appears that variation in IL2RA may confer
risk to various autoimmune diseases but rather not play a
substantial role in the pathogenesis of atopic disorders such as AD.
References
[1] Simpson CR, Anderson WJ, Helms PJ, Taylor MW, Watson L, Prescott GJ, Godden
DJ, Barker RN. Coincidence of immune-mediated diseases driven by Th1 and
Th2 subsets suggests a common aetiology. A population-based study using
computerized general practice data. Clin Exp Allergy 2002;32:3742.
[2] Svejgaard A. The immunogenetics of multiple sclerosis. Immunogenetics
2008;60:27586.
[3] Liu YJ. Thymic stromal lymphopoietin: master switch for allergic inammation.
J Exp Med 2006;203:26973.
[4] Kapp A, Piskorski A, Schopf E. Elevated levels of interleukin 2 receptor in sera of
patients with atopic dermatitis and psoriasis. Br J Dermatol 1988;119:70710.
[5] Hoffjan S, Epplen JT. The genetics of atopic dermatitis: recent ndings and
future options. J Mol Med 2005;83:68292.
[6] Akkad DA, Hoffjan S, Petrasch-Parwez E, Beygo J, Gold R, Epplen JT. Variation in
the IL7RA and IL2RA genes in German multiple sclerosis patients. J Autoimmun
2009;32:1105.
[7] Kurz T, Hoffjan S, Hayes MG, Schneider D, Nicolae R, Heinzmann A, Jerkic SP,
Parry R, Cox NJ, Deichmann KA, Ober C. Fine mapping and positional candidate
studies on chromosome 5p13 identify multiple asthma susceptibility loci. J
Allergy Clin Immunol 2006;118:396402.
[8] Shamim Z, Muller K, Svejgaard A, Poulsen LK, Bodtger U, Ryder LP. Association
between genetic polymorphisms in the human interleukin-7 receptor alpha-
chain and inhalation allergy. Int J Immunogenet 2007;34:14951.
[9] Akkad DA, Arning L, IbrahimSM, Epplen JT. Sex specically associated promoter
polymorphism in multiple sclerosis affects interleukin 4 expression levels.
Genes Immun 2007;8:7036.
[10] Luomala M, Lehtimaki T, Huhtala H, Ukkonen M, Koivula T, Hurme M, Elovaara
I. Promoter polymorphism of IL-10 and severity of multiple sclerosis. Acta
Neurol Scand 2003;108:396400.
[11] Maier LM, Lowe CE, Cooper J, Downes K, Anderson DE, Severson C, Clark PM,
Healy B, Walker N, Aubin C, Oksenberg JR, Hauser SL, Compston A, Sawcer S, De
Jager PL, Wicker LS, Todd JA, Haer DA. IL2RA genetic heterogeneity in multiple
sclerosis and type 1 diabetes susceptibility and soluble interleukin-2 receptor
production. PLoS Genet 2009;5:e1000322.
S. Hoffjan
a,
*, J. Beygo
a
, D.A. Akkad
a,b
, Q. Parwez
c
,
E. Petrasch-Parwez
d
, J.T. Epplen
ab
a
Department of Human Genetics, Ruhr-University,
Bochum, Germany
Table 1
Allele and genotype frequencies of IL7RA and IL2RA SNPs in atopic dermatitis (AD) patients and non-atopic controls. p-values are noted here prior to Bonferroni correction.
Signicant values (indicated in bold letters) remained signicant even after Bonferroni correction for 5 SNPs (IL7RA) or 4 SNPs (IL2RA).
Gene SNP Cohort Alleles (%) p-value Genotypes (%) p-value n
Maj. allele (%) Min. allele (%) Maj./Maj. Maj./Min. Min./Min.
IL7RA rs11567685 AD 504 (71.2) 204 (28.8) 0.4572 178 (50.3) 148 (41.8) 28 (7.9) 0.7458 354
Controls 1292 (72.7) 486 (27.3) 468 (52.6) 356 (40.0) 65 (7.4) 889
IL7RA rs1494555 AD 458 (63.4) 264 (36.6) 0.2798 150 (41.6) 158 (43.8) 53 (14.7) 0.1696 361
Controls 1167 (65.7) 609 (34.3) 376 (42.3) 415 (46.7) 97 (10.9) 888
IL7RA rs6897932 AD 564 (78.6) 154 (21.4) 0.0017 224 (62.4) 116 (32.3) 19 (5.3) 0.0059 359
Controls 1258 (72.5) 478 (27.5) 456 (52.5) 346 (39.9) 66 (7.6) 868
IL7RA rs987106 AD 342 (48.4) 364 (51.6) 0.0021 84 (23.8) 174 (49.3) 95 (26.9) 0.0041 353
Controls 977 (55.3) 791 (44.7) 259 (29.3) 459 (51.9) 166 (18.8) 884
IL7RA rs3194051 AD 486 (71.7) 192 (28.3) 0.7008 175 (51.6) 136 (40.1) 28 (8.3) 0.8662 339
Controls 1242 (72.5) 472 (27.5) 448 (52.3) 346 (40.4) 63 (7.4) 857
IL2RA rs12722489 AD 593 (82.1) 129 (17.9) 0.0944 243 (67.3) 107 (29.6) 11 (3.1) 0.2327 361
Controls 1505 (84.8) 269 (15.2) 636 (71.7) 233 (26.3) 18 (2.0) 887
IL2RA rs2104286 AD 529 (74.5) 181 (25.5) 0.3943 202 (56.9) 125 (35.2) 28 (7.9) 0.7101 355
Controls 1346 (76.1) 422 (23.9) 523 (59.2) 300 (33.9) 61 (6.9) 884
IL2RA rs11256369 AD 557 (77.1) 165 (22.9) 0.0821 210 (58.2) 137 (38.0) 14 (3.9) 0.1926 361
Controls 1305 (73.8) 463 (26.2) 467 (52.8) 371 (42.0) 46 (5.2) 884
IL2RA rs7076103 AD 628 (87.0) 94 (13.0) 0.8828 274 (75.9) 80 (22.2) 7 (1.9) 0.9293 361
Controls 1494 (86.8) 228 (13.2) 648 (75.3) 198 (23.0) 15 (1.7) 861
Table 2
IL7RA and IL2RA haplotype frequencies in atopic dermatitis (AD) patients and non-
atopic controls.
Gene Haplotype AD (n = 361) Controls (n = 908) p-value
IL7RA 1. TGCAA 0.3452 0.2919 0.069
2. TATTA 0.1997 0.2479 0.079
3. TACAA 0.1456 0.1352 0.653
4. CACTG 0.2736 0.2323 0.148
All other infrequent 0.0359 0.0926
IL2RA 1. GAGA 0.0714 0.0711 0.999
2. GAGG 0.4350 0.4323 0.950
3. GACG 0.2233 0.2447 0.465
4. GGGA 0.0484 0.0537 0.675
5. AGGG 0.1530 0.1293 0.276
All other infrequent 0.0689 0.0688
Letters to the Editor / Journal of Dermatological Science 55 (2009) 123141 139
b
IGSN, International Graduate School of Neuroscience,
Ruhr-University, Bochum, Germany
c
Private Medical Practice, Gladbeck, Germany
d
Department of Neuroanatomy and Molecular Brain Research,
Ruhr-University, Bochum, Germany
*Corresponding author at: Department of Human Genetics,
Ruhr-University 44801 Bochum, Germany.
Tel.: +49 234 3223823; fax: +49 234 3214196
E-mail address: sabine.hoffjan@rub.de (S. Hoffjan)
3 February 2009
doi:10.1016/j.jdermsci.2009.05.001
Letter to the Editor
Prevalence of atopic dermatitis in Japanese adults and com-
munity validation of the U.K. diagnostic criteria
To the Editor,
Atopic dermatitis (AD) is a common inammatory skin disease
characterized by chronic, relapsing pruritic eczematous lesions.
Although there have been numerous epidemiological studies on the
prevalence of ADinchildrenandadolescents, there have beenfewin
adults [16]. Most of the studies done were based onquestionnaires
[14]. We evaluated the prevalence of AD in Japanese adults based
on regular health check-ups by dermatologists at Tokyo University
in 2004 [6]. A total of 2123 staff members were examined in the
study. The prevalence of AD was 6.9% overall, and 9.8%, 8.7%, 4.4%
and 2.6%, respectively, for those in their 20s, 30s, 40s and 50s/60s,
with that in women being higher than that in men (9.3% vs. 5.1%).
Overall, 76.7%, 18.5%, 3.4% and 1.4% of those aficted were in the
mild, moderate, severe and very severe groups, respectively [6]. The
objective of this current study was to conrm these results by
evaluating the prevalence of adult AD in other areas of Japan,
because there have been few studies in adults.
A simple list of diagnostic criteria for AD for use in epidemio-
logical studies was developed by a U.K. working party [7]. This list
served well for both hospital patients with skin diseases and in
general population within the U.K. The U.K. diagnostic criteria were
validated in other countries [8] and we also validated them in
Japanese elementary schoolchildren in 2001 and 2004 [9].
ComparingtheU.K. criteriawiththendings onclinical examination
used as the reference standard, the U.K. criteria showed a sensitivity
of 71.8%, specicity of 89.3% and positive predictive value of 44.7%
[9]. To the best of our knowledge, there has beenno validation study
in general adult population. Another objective of this study was to
validate the U.K. criteria in Japanese adults.
For a pre-nationwide study, two more prefectures: Hokkaido
and Osaka were chosen from two other areas: Hokkaido (Northern
Japan) and Kinki (Central to Western Japan), respectively, in
addition to Tokyo prefecture (Kanto area: Eastern Japan). The
target population was staff members visiting the Health Service
Center of Kinki University (Osaka) and Asahikawa Medical College
(Hokkaido) for annual health check-ups in 2007 and 2008,
respectively. Permission was obtained from the Board of the
Health Service Center of both institutions. AD was diagnosed by
experienced dermatologists based on the Japanese Dermatological
Association criteria for the disease [10]. The severity of AD was
graded as mild, moderate, severe or very severe according to the
criteria shown elsewhere [6]. The x
2
-test was used to analyze the
results, and p < 0.05 was considered statistically signicant. A
questionnaire was distributed to the participants before the skin
examination, completed and collected after the survey. The
questions on AD were taken from the U.K. criteria and AD was
also diagnosed using these criteria. Prevalence based on clinical
diagnosis by dermatologists and the U.K. criteria was compared.
Table 1 shows the prevalence and severity of AD at Kinki
University and Asahikawa Medical College. A total of 2137 (1051
men and 1086 women) staff members were examined in this study.
The average age was 40.6 12.0years (men: 44.7 11.6andwomen:
36.7 11.1) rangingfrom20to69years. Theprevalenceof ADwas 6.1%
overall, and 10.5%, 7.8%, 3.9% and 2.5%, respectively, for those in their
20s, 30s, 40s and50s/60s (Table 1). If we discardedthe 20s data inorder
to exclude the inuence of the age of adolescence, the overall
prevalence would be 4.9%. The prevalence of 30s was signicantly
higher thanthat of 40s (p < 0.01). The prevalenceof womenwas higher
than that of men overall (7.3% vs. 4.9%, p < 0.05), although it must be
takenintoconsiderationthat theaverage ageof womenwas lower than
that of men (36.7 years vs. 44.7 years). There was no signicant
difference in prevalence between the two sexes in each generation.
Overall, 84.6% and 15.4% of those aficted were in the mild and
moderate groups, respectively (Table 1). The prevalence of moderate
AD in men was higher than that in women (23.5% vs. 10.1%, p < 0.05).
There was no severe or very severe AD in this study. Among the 2137
staff members, 2120 completed the questionnaire. Comparing the U.K.
criteria with the ndings on clinical examination, the U.K. criteria
showedasensitivityof 68.8%(88/128), specicityof 93.5%(1863/1992)
and positive predictive value of 40.6% (88/217) (Table 2).
The results obtained from the health check-ups at Tokyo
University and those from Kinki University and Asahikawa Medical
College showedthe sametendency: (i) anoverall prevalenceof adult
AD ranging from 5% to 7%; (ii) the prevalence decreased with age,
and especially there was a signicant difference between the 30s
and 40s, suggesting frequent recovery during these ages; (iii)
approximately80%of ADcases wereinthemildgroup. In2003, Muto
et al. [1] reported the prevalence of adult AD in Japan using the
questionnaires. The point prevalence of AD was 2.9%, and no
signicant statistical differences were observed between the sexes
or among age groups within each sex [1]. The discrepancy between
their results and ours is mainly due to the difference of investigative
methodology. Although the number and community in our studies
are still limited, the result suggests that AD is one of the most
common skin diseases not only in children and adolescents but also
in adults, especially in their 20s and 30s. In addition, the results of
validation study for Japanese elementary schoolchildren and those
for adults also indicated the same tendency: the sensitivity and
specicity were about 70%and90%, respectively. Nowthat we know
A R T I C L E I N F O
Article history:
Received 9 February 2009
Keywords:
Prevalence; Atopic dermatitis; Japanese
adults; Validation; U.K. diagnostic criteria
Letters to the Editor / Journal of Dermatological Science 55 (2009) 123141 140